Awake Surgery Research Articles

Heart rate variability analysis for the prediction of pre-arousal during propofol-remifentanil general anaesthesia: A feasibility study.

Accidental awareness during general anaesthesia is a major complication. Despite the routine use of continuous electroencephalographic monitoring, accidental awareness during general anaesthesia remains relatively frequent and constitutes a significant additional cost. The prediction of patients' arousal during general anaesthesia could help preventing accidental awareness and some researchers have suggested that heart rate variability (HRV) analysis contains valuable information about the patient arousal during general anaesthesia. We conducted pilot study to investigate HRV ability to detect patient arousal. RR series and the Bispectral IndexTM (BISTM) were recorded during general anaesthesia. The pre-arousal period T0 was defined as the time at which the BISTM exceeded 60 at the end of surgery. HRV parameters were computed over several time periods before and after T0 and classified as "BISTM<60" or "BISTM≥60". A multivariate logistic regression model and a classification and regression tree algorithm were used to evaluate the HRV variables' ability to detect "BISTM≥60". All the models gave high specificity but poor sensitivity. Excluding T0 from the classification increased the sensitivity for all the models and gave AUCROC>0.7. In conclusion, we found that HRV analysis provided encouraging results to predict arousal at the end of general anaesthesia.

Functional and oncological outcomes following more than three consecutive surgical resections for multiple relapses of initially grade 2 IDH-mutated gliomas.

Second and third surgeries were demonstrated as safe and efficient in recurrent diffuse low-grade glioma (LGG). Here, the feasibility of more than 3 resections is investigated. Patients who underwent 4 or 5 operations for recurrent initially WHO grade 2 IDH-mutated gliomas were consecutively selected. Twenty-three operations were performed in five patients (all males, mean age 27.2 ± 4 years). Three patients underwent 5 surgeries and two patients underwent 4 surgeries. Twelve procedures (52%) were achieved with awake mapping, including all 4th and 5th operations but one. Repeat electrical mapping detected changes of the cortical maps between at least two awake surgeries in 4 patients. No patients experienced permanent neurological impairment (KPS score ≥ 80 in all cases). The patients returned to work after 22 surgeries among 23 (95.6%). There were 3 oligodendrogliomas and 2 astrocytomas (4 gliomas became malignant at fourth or fifth operation). Although the preoperative tumor volume significantly increased before the fourth (p = 0.026) and fifth operation (p = 0.003) compared with the first operation, there was no significant difference between the residual tumor volume after the fourth or fifth resection versus the first one. The mean delay was 10.6 ± 3.9 years before chemotherapy and 15.4 ± 3.4 years before radiotherapy (one patient never received adjuvant treatment after 21.5 years). The mean follow-up duration was 18.3 ± 3.1 years since the first surgery (2.3 ± 1.8 years since the last surgery). Three patients were still alive at last follow-up. This is the first series showing that to reoperate beyond three times is feasible with a low functional risk and a long survival in multiple LGG recurrences, with the use of awake mapping in 87.5% of 4th and 5th surgeries.

Awake thoracic surgery for severe pulmonary hypertension: A case report

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Spontaneous speech: a robust measurement before, during and after awake brain surgery in patients with glioma

Background Patients with glioma often report language complaints with devastating effect on daily life. Analysing spontaneous speech can help to understand underlying language problems. Spontaneous speech monitoring is also of importance during awake brain surgery: it can guide tumour resection and contributes to maintaining language function. We aimed to investigate the spontaneous speech of patients with glioma in the perioperative period and the additional value of spontaneous speech analyses compared to standardised language testing. Methods We elicited and transcribed spontaneous speech of eight patients with glioma elected for awake brain surgery preoperatively, intraoperatively and 2.0–3.5 months postoperatively. Linguistic errors were coded. Type Token Ratio, Mean Length of Utterance of words, minimal utterances, and errors were extracted from the transcriptions. Patients were categorised based on total error patterns: stable, decrease or increase during surgery. Reliable Change Index scores were calculated for all spontaneous speech variables to objectify changes between time points. Language performance on language tests was compared to spontaneous speech variables. Results Most errors occurred in lexico-syntax, followed by phonology/articulation, syntax, and semantics. The predominant errors were Repetitions, Self-corrections, and Incomplete sentences. Most patients remained stable over time in almost all spontaneous speech variables, except in Incomplete sentences, which deteriorated in most patients postoperatively compared to intraoperatively. Some spontaneous speech variables (total errors, MLUw, TTR) gave more information on language change than a standard language test. Conclusions While the course of spontaneous speech over time remained relatively stable in most patients, Incomplete sentences seems to be a robust marker of language difficulties patients with glioma. These errors can be prioritised in spontaneous speech analysis to save time, especially to determine intra- to postoperative deterioration. Importantly, spontaneous speech analyses can give more information on language change than standardised language testing and should therefore be used in addition to standardised language tests.

MULTIMODAL (5-ALA, TRACTOGRAPHY AND ULTRASOUND GUIDED) AWAKE CRANIOTOMY FOR GLIOBLASTOMA: MAXIMISING SAFE SURGICAL RESECTION

Abstract AIMS Maximising the extent of surgical resection of glioblastoma is a key prognostic factor for survival. This must be balanced against avoiding neurological deficit, which may delay or preclude adjuvant treatments. This is a particular challenge in eloquent tumours. Optimal surgical adjuncts to enable maximal resection of glioblastomas in eloquent brain regions, remain unclear. We present the first series assessing the safety and efficacy of multimodality image-guided, awake resection of IDH-wildtype glioblastoma, combining 5-aminolevulinic acid (5-ALA), diffusion tractography (DTI) and intraoperative ultrasound (USS). METHOD We present a single centre retrospective series of 175 patients undergoing awake craniotomy for primary resection of glioblastomas, between January 2014 and January 2023. Awake craniotomy was considered if tumours were in or adjacent to eloquent areas. Key outcomes assessed included post-operative neurological complications (classified into transient, if persisting &amp;lt;3 months and completely resolved, or permanent if persisting &amp;gt;3 months), extent of resection (EOR) and overall survival (OS). RESULTS 175 patients (103M:72F) were included, with a mean age of 58.2 years. All cases used neuronavigation, whilst 5- ALA and DTI were used in 98.9% and 97.1% of patients respectively. Intraoperative USS was used 88/175 (50.3%). Gross total resection (&amp;gt;98%) was achieved in 101/175 patients (64.7%). 83/175 patients (47.4%) experienced a post-operative neurological deficit, which was temporary in 84.3% (70/83) of cases. When transient deficits occurred, these were most often speech related (49/70). Subgroup analysis found left temporal tumours were highest risk for transient dysphasia (59.2%), followed by left frontal (21.7%) and left parietal (16.0%). The median percentage EOR with USS was 100%, whilst without USS was 97.8% (Wilcox, p=0.0004). CONCLUSION Patients should be counselled about the high risk of transient neurological complications following awake surgery, particularly speech deficit. Multimodal image-guided surgery can maximise the extent of safe resection for glioblastoma.

Experiences in Awake Craniotomy from Borneo: A Case Series from Sarawak General Hospital.

The indications for awake craniotomy now spans from resection of tumours at eloquent areas of the brain, deep brain stimulation and treatment of aneurysms to name a few. In the region of East Malaysia where patients have various ethnic backgrounds and native languages, planning and execution of these procedures can be somewhat challenging. This is a retrospective analysis of 11 awake surgeries conducted by the Department of Neurosurgery in Sarawak. The indications for awake craniotomy surgery in our sample population were intra-axial lesions in eloquent regions involving important cortical areas and subcortical tracts which were at risk of damage during tumour excision. Patients were assessed for intra-operative and post-operative neurological deficits. Eleven patients aged 20 years old-70 years old were included in this series. All patients were diagnosed with lesions in eloquent areas of the brain requiring surgical excision. Patients were of various ethnic backgrounds. The spoken language of these patients also varied based on their ethnicity. The histopathological diagnosis of nine patients were consistent with gliomas with three being of high grade. Three patients (27%) developed intra-operative deficits that were not present pre-operatively. This case series serve to demonstrate the feasibility of awake craniotomies even in centres without vast experiences in awake surgeries and ideal adjuncts which in comparison may be readily available in different centres. Although careful patient selection has been emphasised, it is a difficult feat in a region consisting of at least 30 different ethnic groups with distinct languages and cultures.

Awake Surgery for Right Frontal Lobe Glioma: Preserving Emotional Recognition and Facilitating Early Return to Work.

Many glioma patients struggle to return to work after surgery because of higher brain dysfunction. Although the right frontal lobe has historically been considered functionally silent, reports of performing awake surgery to evaluate higher brain functions in patients with tumors in this area have increased. We present two cases of patients who underwent awake surgery for malignant glioma in the right frontal lobe to preserve emotional recognition and facilitate an early return to work. Case 1 was a 48-year-old right-handed woman employed as a nursery school teacher and case 2 was a 21-year-old right-handed man employed in sales. Both had contrast-enhancing right frontal lobe tumors exhibiting high signal intensity on fluid attenuated inversion recovery imaging and underwent awake surgery. During the operation, cortical mapping was performed using the Reading the Mind in the Eyes, calculation, and motor tasks. Resection of sites involved in motor and emotional recognition functions was avoided. In case 1, all regions of high signal intensity were completely resected; in case 2, all regions exhibiting enhancement were resected. Both patients were discharged home without neurological deficits and returned to work within 21 days after surgery. It may be important to focus not only on overall survival and progression-free survival in glioma patients, but also on factors associated with life satisfaction, such as time to return to work after surgery and time until work becomes difficult. Awake surgery aimed at preserving higher brain functions is useful and may also improve life satisfaction.

A Comparative Study of Intraoperative Awareness Using Modified Brice Questionnaire in Patients Undergoing Emergency and Elective Surgery under General Anaesthesia

A Comparative Study of Intraoperative Awareness Using Modified Brice Questionnaire in Patients Undergoing Emergency and Elective Surgery under General Anaesthesia

The dose of remimazolam combined with sufentanil for the induction of general anesthesia in obese patients undergoing bariatric surgery: an up-and-down sequential allocation trial.

Background and purpose: Remimazolam is a newly developed benzodiazepine drug with water-soluble, esterase degradation, and ultra-short-acting properties. The dose for general anesthesia induction in obese patients was not known. This study aimed to determine the optimal dose of remimazolam in combination with sufentanil for the induction of general anesthesia in obese patients. Methods: It was a prospective observational study. We recruited 46 patients scheduled for bariatric surgery from October 2022 to December 2023. One patient refused to provide informed consent, and six patients were receiving psychotropic medication. Thirty-nine patients were enrolled. The Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale was used to assess the patient's response. The dose of sufentanil was 0.5 µg/kg (lean body weight [LBW]). The initial dose of remimazolam was 0.3mg/kg (LBW). The dose of remimazolam was modified using the up-and-down allocation technique. Successful sedation (negative group) was characterized by achieving a MOAA/S score ≤ 1 within 3min of commencing remimazolam infusion. If negative, the next patient received a low-level dose at a ratio of 0.9. Failed sedation (positive group) was defined as a MOAA/S score of >1 within 3min of commencing remimazolam infusion. The patients in the positive group received propofol 0.5mg/kg as a remedial measure, and the next dose was increased to a higher level. The primary outcome was to determine the half-effective dose (ED50) and 95% effective dose (ED95) of remimazolam in combination with sufentanil 0.5 µg/kg for induction in obese patients. The secondary outcome was to determine the occurrence of adverse effects such as hypotension, hypertension, and intraoperative awareness. Results: The ED50 and ED95 values of remimazolam (LBW) combined with sufentanil (0.5 µg/kg) (LBW) were 0.115mg/kg (95% CI: 0.072-0.137) and 0.179mg/kg (95% CI: 0.150-0.434), respectively, and the time of loss of consciousness in the negative group was 120.13 ± 25.03s. The cardiovascular system was stable during the induction period. The incidence of post operative nausea and vomiting (PONV) was 38.5% in 39 patients. Respiratory depression, allergic reaction, intraoperative awareness, and delayed emergence were not observed in any patient. Conclusion: Remimazolam combined with sufentanil (0.5 µg/kg) (LBW) can be effectively used for general anesthesia induction in obese patients. The ED50 and ED95 values of remimazolam (LBW) were 0.115mg/kg and 0.179mg/kg, respectively. Clinical Trial Registration: www.chictr.org.cn, identifier ChiCTR2200065602.

Minimally-invasive trans-facet lumbar interbody fusion using a dual-dimension expandable cage: preliminary results of a multi-institutional retrospective study.

Minimally-invasive trans-facet lumbar interbody fusion (LIF) is an emerging technique that offers the advantages of being safe, enabling decompression, and facilitating patient recovery. An innovative cage that expands in two dimensions has been introduced to restore segmental lordosis and disc height while minimizing the risk of cage subsidence. This study aimed to report our surgical technique of trans-facet LIF utilizing the innovative cag and to report the early clinical outcomes. We retrospectively reviewed the medical records and radiographs of patients who underwent trans-facet LIF with dual-dimension expandable cages from two institutions: Duke University Hospital and Vail-Summit Orthopaedics and Neurosurgery. The analysis covered patient demographics, Oswestry Disability Index (ODI), visual analogue scale (VAS) for back pain, surgical data, complications, and radiographic parameters. Clinical outcomes were compared between pre- and one year post-operation, while radiographic outcomes were compared between pre- and three months post-operation. Twenty patients with a mean age of 61.2 years were included. Seventeen patients (85.0%) had spondylolisthesis, and L4/5 (68.2%) was the most common pathology level. Twelve patients (60.0%) underwent awake surgery, and the mean operative time was 164.5±36.1 minutes, with an estimated blood loss of 64.0±39.5 mL and a hospital stay of 1.75±1.2 days. Four patients (20.0%) experienced cage subsidence; however, none required additional surgery. The VAS score significantly improved from a preoperative average of 7.3±2.7 to 2.6±1.6 one year post-operation (P=0.02). The ODI score also showed a significant decrease, from 48.7±22.9 preoperatively to 16.4±11.1 one year postoperatively (P=0.03). Notably, 80% and 83.3% of patients achieved the minimum clinically important difference in VAS and ODI scores, respectively. The degree of spondylolisthesis was significantly reduced from a median of 5.9 mm preoperatively to 0 mm postoperatively (P<0.001). Additionally, both anterior and posterior disc heights significantly increased after surgery, from 9.8±4.7 to 15.1±2.6 mm (anterior) and from 4.9±3.3 to 10.5±2.2 mm (posterior) (P<0.001 for both). The mean segmental lordosis increased by 2.9 degrees and was associated with cage height (P=0.03), while spinopelvic parameters remained unchanged. Minimally-invasive trans-facet LIF with dual-dimension expandable cages demonstrates a substantial capacity for spondylolisthesis reduction and disc height restoration, and provides good short-term clinical outcomes. It may be the most appropriate method for deploying this large cage as it allows for a large, unobstructed pathway to the disc. However, future studies are needed to determine the long-term outcomes, including the arthrodesis rate.

Is the combination of interfascial plane blocks sufficient for awake breast cancer surgery? An observational, prospective, proof-of-concept study

IntroductionBreast cancer is the most prevalent cancer among women, often necessitating surgical intervention. While surgeries like lumpectomy can be performed under local anesthesia, more extensive procedures typically require general anesthesia. Awake breast cancer surgery has emerged as an alternative due to risks associated with general anesthesia and patient preference.MethodsThis prospective observational study, conducted from July 2022 to July 2023, evaluated the effectiveness of ultrasound-guided fascial plane blocks for awake breast surgery. Patients aged 18–80 years undergoing unilateral breast surgery were included, following ethical committee approval and written informed consent. Exclusion criteria were prior breast surgery, coagulopathies, infections, allergies to local anesthetics, psychiatric disorders, body mass index over 40 kg/m², and chest deformities. The combination of interpectoral, pecto-serratus, and deep serratus plane blocks was used as the primary anesthetic method, with a superficial parasternal block added in cases where complete cutaneous coverage was not achieved.ResultsSeventeen patients were enrolled. The primary outcome, sufficient surgical anesthesia without deep sedation, was achieved in 15 patients. The combination of the aforementioned blocks proved effective, with an average surgery duration of 59.66 min, and propofol requirements averaging 1.77 mg/kg/hour. Most patients reported high satisfaction levels, and no early or late block-related complications were observed.ConclusionThe combination of fascial plane blocks is a viable option for awake breast cancer surgery, potentially eliminating the need for more invasive anesthesia techniques. Further studies are necessary to confirm these findings in larger, homogeneous patient groups.

Accurate Machine Learning-based Monitoring of Anesthesia Depth with EEG Recording.

General anesthesia, pivotal for surgical procedures, requires precise depth monitoring to mitigate risks ranging from intraoperative awareness to postoperative cognitive impairments. Traditional assessment methods, relying on physiological indicators or behavioral responses, fall short of accurately capturing the nuanced states of unconsciousness. This study introduces a machine learning-based approach to decode anesthesia depth, leveraging EEG data across different anesthesia states induced by propofol and esketamine in rats. Our findings demonstrate the model's robust predictive accuracy, underscored by a novel intra-subject dataset partitioning and a 5-fold cross-validation method. The research diverges from conventional monitoring by utilizing anesthetic infusion rates as objective indicators of anesthesia states, highlighting distinct EEG patterns and enhancing prediction accuracy. Moreover, the model's ability to generalize across individuals suggests its potential for broad clinical application, distinguishing between anesthetic agents and their depths. Despite relying on rat EEG data, which poses questions about real-world applicability, our approach marks a significant advance in anesthesia monitoring.

Clinico-physiological correlates of Parkinson’s disease from multi-resolution basal ganglia recordings

Parkinson’s disease (PD) has been associated with pathological neural activity within the basal ganglia. Herein, we analyzed resting-state single-neuron and local field potential (LFP) activities from people with PD who underwent awake deep brain stimulation surgery of the subthalamic nucleus (STN; n = 125) or globus pallidus internus (GPi; n = 44), and correlated rate-based and oscillatory features with UPDRSIII off-medication subscores. Rate-based single-neuron features did not correlate with PD symptoms. STN single-neuron and LFP low-beta (12–21 Hz) power and burst dynamics showed modest correlations with bradykinesia and rigidity severity, while STN spiketrain theta (4–8 Hz) power correlated modestly with tremor severity. GPi low- and high-beta (21–30 Hz) power and burst dynamics correlated moderately with bradykinesia and axial symptom severity. These findings suggest that elevated single-neuron and LFP oscillations may be linked to symptoms, though modest correlations imply that the pathophysiology of PD may extend beyond resting-state beta oscillations.

Spinal Anesthesia for Awake Spine Surgery: A Paradigm Shift for Enhanced Recovery after Surgery.

Awake surgery has been applied for various surgical procedures with positive outcomes; however, in neurosurgery, the technique has traditionally been reserved for cranial surgery. Awake surgery for the spine (ASFS) is an alternative to general anesthesia (GA). As early studies report promising results, ASFS is progressively gaining more interest from spine surgeons. The history defining the range of adverse events facing patients undergoing GA has been well described. Adverse reactions resulting from GA can include postoperative nausea and vomiting, hemodynamic instability and cardiac complications, acute kidney injury or renal insufficiency, atelectasis, pulmonary emboli, postoperative cognitive dysfunction, or malignant hyperthermia and other direct drug reactions. For this reason, many high-risk populations who have typically been poor candidates under classifications for GA could benefit from the many advantages of ASFS. This narrative review will discuss the significant historical components related to ASFS, pertinent mechanisms of action, protocol overview, and the current trajectory of spine surgery with ASFS.

Postoperative Outcomes of the Awake Colorectal Surgery with Neuraxial Anaesthesia.

To determine the outcome of awake surgery with combined spinal epidural in geriatric colon cancer patients with advanced comorbidity. Quasi-experimental study. Place and Duration of the Study: Department of Anaesthesiology and Reanimation, Ankara Bilkent City Hospital, Ankara, Turkiye, from April 2022 to 2023. Twenty-four American Society of Anaesthesiologists (ASA) I-II patients, aged 25-65 years and scheduled for colon cancer surgery were included in this research. All patients were observed preoperatively, at the operation room and at the postoperative surgery service. Spinal anaesthesia was planned for Group I and general anaesthesia for Group II. Ketofol (1:1) was administered to the combined spinal-epidural group, with a Ramsay sedation score of 3 after the spinal block. Epidural analgesia was planned for all patients. Patients' age, gender, weight, comorbidities, ASA risk scores, intraoperative haemodynamic parameters, bleeding amounts, colloid, crystalloid, and blood products were collected. There was no significant difference between the demographic characteristics of both anaesthesia groups (p >0.05). The amount of bleeding was statistically lower in Group I than in the general anaesthesia group (p = 0.004). Oral intake, drain withdrawal, mobilisation, discharge times, and costs were similar in all groups (p >0.05). The regional anaesthesia applications facilitate compliance with routine mobilisation, discharge procedures and prevent complications in abdominal surgery and its positive perioperative effects in patients with poor respiratory parameters, poor general condition, and high comorbidity in advanced age. Regional anaesthesia, Spinal-epidural, Mobilisation, Pain, Colon cancer.

The effect of common parameters of bipolar stimulation on brain evoked potentials

ObjectiveTo identify optimal bipolar stimulation parameters for robust generation of brain evoked potentials (BEPs), namely the interelectrode distance (IED) and the intensity of stimulation (IS), in cortical and axonal stimulation. MethodsIn 15 patients who underwent awake surgery for brain tumor removal, BEPs were elicited at different values of IED and IS, respectively: 5 mm-5 mA, 5 mm-10 mA, and 10 mm-10 mA. The number of BEPs elicited by stimulation, as well as the delays and amplitudes of the N1 waves were compared between the different groups of stimulation parameters and according to the stimulated brain structure (cortical vs. axonal). ResultsThe amplitudes of N1 increased with the intensity of bipolar stimulation, either in cortical or axonal stimulation, while N1 peak delays were not affected by the stimulation parameters. Furthermore, axonal stimulation produced more N1s than cortical stimulation, with lower latencies. ConclusionsUnderstanding the relationship between stimulation parameters and BEP is of utmost importance to determine whether the generated N1 waves accurately reflect the underlying structural anatomy. Other factors, such as stimulation frequency or pulse width and shape, may also play a role and warrant further investigation. SignificanceThis study represents the first step in describing the influence of common bipolar stimulation parameters on robustness of BEPs by examining the impact of IED and IS on the N1 wave.

Effects of Music Therapy on Postoperative Pain Perception in Patients Undergoing Abdominal Surgeries Under General Anesthesia: A Prospective Controlled Randomized Comparative Clinical Study.

Background Music therapy has been shown to reduce the need for sedation and analgesics, as well as lower plasma cortisol and epinephrine levels in patients undergoing regional anesthesia. This study evaluates the efficacy of perioperative music therapy in reducing pain perception and its impact on cortisol levels. Materials and methods This prospective randomized control trial was conducted at the tertiary care center in Western Maharashtra. Sixty adult patients (males/females) undergoing elective lower abdomen surgery were included and randomized equally into two groups to listen to music using headphones at a preselected volume (Group M) or to use only headphones without any music played (Group C) for 2 hours in the preoperative, intraoperative, and postoperative periods. Demographic information, anthropometric (height, weight), and biochemical (serum cortisol) measurements were performed. American Society of Anesthesiologists (ASA) grades 1 and 2, and patients aged 18 to 65 years were included. Pain perception was assessed using the Visual Analog Scale (VAS). Results The demographic data, including mean age, BMI, ASA status, average duration of anesthesia, and average duration of surgery, were comparable between the two groups. Group M showed improved control of systolic blood pressure (SBP) at 10- and 30-minutepost-induction of general anesthesia and had a significantly lower VAS score (p < 0.05). Additionally, patient satisfaction was higher in Group M (81.4%) compared to Group C (51.4%) with a p-value of < 0.05. Intraoperative awareness was non-significant between the groups. Conclusion Music therapy is a safe, cost-effective, and efficacious method for reducing pain perception and can be used in conjunction with other treatments for postoperative pain management.

A Meta-Analysis of Medication Reduction and Motor Outcomes After Awake Versus Asleep Deep Brain Stimulation for Parkinson Disease.

There remains significant debate regarding the performance of deep brain stimulation (DBS) procedures for Parkinson disease (PD) under local or general anesthesia. The aim of this meta-analysis was to compare the clinical outcomes between "asleep" DBS (general anesthesia) and "awake" DBS (local anesthesia) for PD. We conducted a comprehensive literature review of all published studies on DBS for PD following PRISMA guideline on PubMed and Cochrane library from January 2004 to April 2023. Inclusion criteria included cohort ≥15 patients, clinical outcomes data which included Unified Parkinson's Disease Rating Scale (UPDRS) score and levodopa equivalent daily dosage (LEDD), and ≥3 months of follow-up. Analysis was conducted using Stata software. There were 18 articles that met inclusion criteria. On meta-analysis, there were no significant differences between awake or asleep DBS with regard to percent change in UPDRS III "off" med/"on" DBS condition (P = .6) and LEDD score (P = .99). On subgroup analysis, we found that the choice of target had no significant effect on improvement of UPDRS III (P = 1.0) or LEDD (P = .99) change for the asleep vs awake operative approach. There were also no statistically significant differences between microelectrode recording (MER) use and no MER use in postoperative UPDRS III (P = 1.0) or LEDD improvement (P = .90) between awake and asleep surgery. There was no significant difference in the primary motor outcomes and LEDD improvement between asleep vs awake DBS. The variables of target selection and MER use had no statistically significant impact on outcome. We find that asleep techniques are both safe and effective compared with the awake technique.

The role of postoperative blood pressure management in early postoperative hemorrhage in awake craniotomy glioma patients

Postoperative hemorrhage can severely affect the patients’ neurological outcome after awake craniotomy. Higher postoperative blood pressure can increase the risk of postoperative hemorrhage. The aim of this study was to investigate the role of postoperative blood pressure and other common radiological and epidemiological features with the incidence of postoperative hemorrhage. In this retrospective analysis, we included patients who underwent awake surgery at our institution. We assessed the blood pressure both intra- and postoperatively as well as the heart rate for the first 12 h. We compared a cohort with postoperative hemorrhage, who required further treatment (surgical revision or intravenous antihypertensive therapy), with a cohort with no postoperative hemorrhage. We included 48 patients with a median age of 39 years. 9 patients (19%) required further treatment due to postoperative hemorrhage, which was surgery in 2 cases and intensive blood pressure measurements in 7 cases. However, with early treatment, no significant difference in Performance scores at follow-up could be found. Patients with postoperative hemorrhage showed significantly higher postoperative systolic blood pressure during the hours 3–12 (p < 0.05) as well as intraoperatively throughout the procedure (p < 0.05). In ROC and Youden Test, a strong impact of systolic blood pressure over 140mmHg during the early postoperative course could be shown. Postoperative hemorrhage is a rare but possible complication in awake surgery glioma patients. To avoid postoperative hemorrhage, treating physicians should aim strictly on systolic blood pressure of under 140mmHg for the postoperative course.

Opioid-Free Using Ketamine versus Opioid-Sparing Anesthesia during the Intraoperative Period in Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

Opioids effectively manage perioperative pain but have numerous adverse effects. Opioid-free anesthesia (OFA) eliminates intraoperative opioid use; however, evidence for its use in video-assisted thoracoscopic surgery (VATS) is limited. This study assessed the effect of OFA using ketamine in VATS patients compared to opioid-sparing anesthesia (OSA). A total of 91 patients undergoing VATS lobectomy or segmentectomy were randomized to either the OFA group (ketamine) or the OSA group (remifentanil). The primary outcome was the quality of recovery (QoR) on postoperative day (POD) 1, measured with the QoR-40 questionnaire. Secondary outcomes included postoperative pain scores and adverse events. Both groups had comparable baseline and surgical characteristics. On POD 1, the QoR-40 score was higher in the OFA group than in the OSA group (164.3 ± 10.8 vs. 158.7 ± 10.6; mean difference: 5.6, 95% CI: 1.1, 10.0; p = 0.015), though this did not meet the pre-specified minimal clinically important difference of 6.3. The visual analog scale score was lower in the OFA group as compared to the OSA group at 0-1 h (4.2 ± 2.3 vs. 6.2 ± 2.1; p < 0.001) and 1-4 h after surgery (3.4 ± 1.8 vs. 4.6 ± 1.9; p = 0.003). The OFA group had a lower incidence of PONV (2 [4.4%] vs. 9 [19.6%]; p = 0.049) and postoperative shivering (4 [8.9%] vs. 13 [28.3%]; p = 0.030) than the OSA group at 0-1 h after surgery. Using OFA with ketamine proved feasible, as indicated by the stable intraoperative hemodynamics and absence of intraoperative awareness. Patients undergoing VATS with OFA using ketamine showed a statistically significant, but clinically insignificant, QoR improvement compared to those receiving OSA with remifentanil.